Back to Program


The Posterior Approach To Transperitoneal Robotic Assisted Radical Prostatectomy: Detailed Technique
Alireza Moinzadeh, MD, Andrea Sorcini, MD, David Canes, MD.
Lahey Clinic Medical Center, Burlington, MA, USA.

BACKGROUND: The technical description of laparoscopic prostatectomy from Montsouris in 2000 included an initial posterior retrovesical approach to the vas and seminal vesicles, followed by Denonviller's fascia incision and posterior release of the rectum. At that time, the feasibility of dissecting these structures following the posterior bladder neck dissection was not known, and therefore the posterior approach was largely performed out of necessity.
Currently, the majority of minimally invasive surgeons perform an anterior approach to the vas and seminal vesicle dissection, and the anatomy of an initial posterior dissection is therefore unfamiliar. Since April 2009, the senior author (DC) has switched to the posterior approach, and in this video the subjective advantages are discussed, and the technique demonstrated.
METHODS:
Between April 2009 and April 2010, a posterior approach was attempted in 89 consecutive transperitoneal robotic prostatectomies. A four-arm DaVinci S-HD system was employed, with the fourth arm on the patient's right side, and the assistant on the left. Pertinent steps are as follows: (1) release of native sigmoid attachments from the posterior parietal peritoneum (2) retraction of the sigmoid out of the pelvis by the bedside assistant (3) horizontal peritoneotomy at the lower peritoneal fold (2) bilateral vas identification (3) vas transection (4) seminal vesicle identification and mobilization with judicious use of bipolar electrocautery (5) dissection above the vas/seminal vesicles to the prostate base (6) Denonvillier's fascia incision (7) release of rectum in the midline.
RESULTS:
In one patient, the posterior approach could not be performed, as prior diverticulitis had created significant sigmoid adhesions in the cul-de-sac, and further dissection was not attempted. The posterior approach was performed in 88 patients. Estimated blood loss was 140 mL (50-800), operative time averaged 205 min (115-410). Pathologic stage was <= pT2c in 75, and pT3 or higher in 13. Surgical margins were positive in 11 (12.5%) of patients.
Subjective advantages include a large working space for dissection, reproducible presentation of the anatomy, and ease of resident education. In challenging cases, uncertainty in identifying the vas and seminal vesicles is virtually eliminated.
CONCLUSIONS:
The approach to the vas and seminal vesicles is guided by surgeon preference. Whether or not one chooses to adopt this approach, knowledge of the technique provides flexibility in difficult cases.
The posterior approach has some perceived advantages, which are most pronounced for large prostates, where the anterior approach provides a limited working space. Anatomical landmarks from the posterior approach are reproducible and easy to learn.


Back to Program